Re: Response to In regard to Ding et al. 2020: “Managing Cancer and Living Meaningfully (CALM) Intervention on Chemotherapy Related Cognitive Impairment in Breast Cancer Survivors”

Dear Editor,

We read carefully the Letter to the Editor sent by Professor Giuliana Zarrella and colleagues at Virginia Commonwealth University and appreciated the interest that these eminent colleagues have shown in our work.

The exploration of applying Managing Cancer And Living Meaningfully (CALM) to breast cancer survivors (BCs) with cognitive dysfunction began with our confusion in clinical work. There are many subjective complaints about chemotherapy-related cognitive impairment (CRCI) from BCs clinically, and their lives were also affected to different degrees. We often comfort these BCs that such situation will gradually get better with time, but we also hope there is something can be done to help BCs stay away from trouble of CRCI. While methods like transcranial magnetic stimulation (rTMS) for treatment of cognitive symptoms in patients with Alzheimer’s disease (AD) seems to be excessive, simple comfort has no clear reference value. At this moment, we met Professor Gary Rodin et al teaching CALM to medical workers in China. The CALM is a brief, semi-structured psychotherapeutic intervention adapted to alleviate depression and psychiatric distress in patients with advanced cancer. ¹ It has also been added to the Chinese Psychsocial Oncology Clinical Practice Guidelines 2020 and CACA Technical Guidelines For Holistic Integrative Management of Cancer-Psychotherapy.

As we know, depressive symptoms and cognitive complaints often coexist in BCs. ² Previous studies have also consistently highlighted the correlation between cognitive complaints and depression. ³ In this context, whether CALM can alleviate the cognitive impairment of BCs while alleviating depression and psychological distress has aroused our curiosity. On this basis, we initially supplied CALM for BCs who subjectively complained of cognitive decline, and the final cognitive function assessment found that patients’ psychological distress and self-perceived cognitive complaints decreased after CALM. Then we continued to include more BCs for further analysis. In fact, it can also be observed in clinical work that BCs of different stages have a high degree of interest in the topics of CALM. Considering that BCs with serious psychological distress may feel ambiguous about the extent of cognitive impairment, we included more BCs with moderate psychological distress. We suppose that CALM may improve self-perceived cognitive function by alleviating the level of psychological distress and depressed mood. Such specific mechanism still needs further research, and psychoneuroimmunology may be an important direction. ⁴

The care as usual (CAU) group means that patients receive usual care and verbal comfort without fixed structure. The improvement of the Mini-Mental Status Exam (MMSE) in both groups may be related to the passage of time, and considerable future work is needed to definitively explain such situation. We agree with the view that change index should be calculated to determine whether a clinically meaningful change was observed on the MMSE across time. This suggestion has valuable implications for guiding the estimate of objective cognition.

We agree about the need to measure CRCI based on International Cancer and Cognition Task Force (ICCTF) ⁵ and neuropsychological recommendations and about providing CALM in its evidence-based context. Once again, we thank Prof. Giuliana Zarrella and Prof. Sarah Braun for their valuable recommendations and praise. We hope to work with global oncology psychologists to help more patients obtain both psychological and physical recovery in the future.